Dermatology of Seattle

13610 First Avenue South, Seattle, WA 98168

206-248-5020 – 206-244-8425 (fax)

 

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

 

Patient Name: _______________________             Date of Birth: _____/_____/_____

SSN: ______________________________              Previous Name: ________________

 

I request and authorize: Name: ______________________________________________­­­­

                                    Address: _____________________________________________

                                    City/State/Zip: ________________________________________

Phone: Fax: ________________________

 

to release the healthcare information of the patient named above to:

Name: ______________________________________________

                        Address: ____________________________________________

                                    City/State/Zip: ________________________________________

                                    Phone: Fax: ________________________

 

This request and authorization applies to: (please initial the appropriate box)

q      Healthcare information relating to the following treatment, condition, or dates of treatment: ________________________________________________________

q      All healthcare information EXCLUDING specific information relating to sexually transmitted diseases (including HIV/AIDS), alcohol or drug use, or visits related to psychiatric disorders/mental health.

q      All healthcare information INCLUDING specific information relating to sexually transmitted diseases (including HIV/AIDS), alcohol or drug use, or visits related to psychiatric disorders/mental health.

q      Other: ___________________________________________________________

 

I understand that my express consent is required to release any healthcare information related to testing, diagnosis and/or treatment for HIV/AIDS virus, sexually transmitted disease, psychiatric disorders/mental health, or drug and/or alcohol use. If I have been tested, diagnosed, or treated for HIV/AIDS virus, sexually transmitted disease, psychiatric disorders/mental health, or drug and/or alcohol use, you are specifically authorized to release all healthcare information relating to such diagnosis, testing, or treatment.

 

 

____________________________________                                    _____/_____/_____

Patient or patient’s authorized representative                                               Date

 

 

____________________________________

Relationship or status if signed by anyone other than patient